David Perlstein, MD, MBA, FAAP

Dr. Perlstein received his Medical Degree from the University of Cincinnati and then completed his internship and residency in pediatrics at The New York Hospital, Cornell medical Center in New York City. After serving an additional year as Chief Pediatric Resident, he worked as a private practitioner and then was appointed Director of Ambulatory Pediatrics at St. Barnabas Hospital in the Bronx.

William C. Shiel Jr., MD, FACP, FACR

Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

What is tetanus?

Tetanus is an acute, often-fatal disease of the nervous system that is caused by nerve toxins produced by the bacterium Clostridium tetani. This bacterium is found throughout the world in the soil and in animal and human intestines. The bacterium can also lay dormant in its spore form for years before becoming activated and developing into a regularly reproducing bacterium.

Where do tetanus bacteria grow in the body?

Contaminated wounds are sites where tetanus bacteria multiply. Deep wounds or those with dead tissue are particularly prone to tetanus infection.

Puncture wounds, such as those caused by nails, splinters, or insect bites, are favorite locations of entry for the bacteria. The bacteria can also be introduced through burns, any break in the skin, and injection-drug sites. Tetanus can also be a hazard to both the mother and newborn child (by means of the uterus after delivery and through the umbilical cord stump).

The potent toxin that is produced when the tetanus bacteria multiply is the major cause of harm from tetanus.

How does the tetanus toxin cause damage to the body?

The tetanus toxin affects the interaction between the nerve and the muscle that it stimulates, specifically at the neuromuscular junction. The tetanus toxin amplifies the chemical signal from the nerve to the muscle, which causes the muscles to tighten up in a continuous ("tetanic" or "tonic") contraction or spasm. This results in either localized or generalized muscle spasms. Tetanus toxin can affect neonates to cause muscle spasms, inability to nurse, and seizures. This typically occurs within the first two weeks after birth and can be associated with poor sanitation methods in caring for the umbilical cord stump of the neonate. Of note, because of tetanus vaccination programs, first introduced in the late 1940s, tetanus infection rates have dropped substantially. In fact, according to the World Health Organization, there have only been three cases of neonatal tetanus reported in the U.S. since 2000. In each of these cases, the mothers were incompletely immunized. Unfortunately, throughout the world, tetanus is still common. In 2014, there were over 2,000 cases of neonatal tetanus and over 9,000 cases of non-neonatal tetanus. In comparison, there were 114,000 overall cases reported in 1980.

Do You Need a Tetanus Shot?

The bacteria that cause tetanus can be found in soil,
manure, or dust. They infect humans by entering the body through cuts or
puncture wounds, particularly when the wound area is dirty. Animal bites, burns,
and non-sterile injection of drugs can also lead to infection with Clostridium
tetani.

What is the incubation period for tetanus?

The incubation period between exposure to the bacteria in a contaminated wound and development of the initial symptoms of tetanus ranges from two days to two months, but it's commonly within 14 days of injury.

What is the course of tetanus? What are tetanus symptoms and signs?

During a one- to seven-day period, progressive muscle spasms caused by the tetanus toxin in the immediate wound area may progress to involve the entire body in a set of continuous muscle contractions. Restlessness, headache, and irritability are common.

The tetanus neurotoxin causes the muscles to tighten up into a continuous ("tetanic" or "tonic") contraction or spasm. The jaw is "locked" by muscle spasms, giving the name "lockjaw" (also called "trismus"). Muscles throughout the body are affected, including the vital muscles necessary for normal breathing. When the breathing muscles lose their power, breathing becomes difficult or impossible and death can occur without life-support measures (mechanical ventilation). Even with breathing support, infections of the airways within the lungs can lead to death.

Is tetanus contagious?

Tetanus is not contagious. You cannot "catch" tetanus from another infected individual. That means one person cannot be infected by another individual by coming in contact with secretions or other exposures. The bacterial spores must enter a wound to develop into an infection.

What is the treatment for tetanus?

General measures to treat the sources of the bacterial infection with antibiotics and drainage are carried out in the hospital while the patient is monitored for any signs of compromised breathing muscles. Treatment is directed toward stopping toxin production, neutralizing its effects, and controlling muscle spasms. Sedation is often given for muscle spasm, which can lead to life-threatening breathing difficulty.

In more severe cases, breathing assistance with an artificial respirator machine may be needed.

The toxin already circulating in the body is neutralized with antitoxin drugs. The tetanus toxin causes no permanent damage to the nervous system after the patient recovers.

After recovery, patients still require active immunization because having the tetanus disease does not provide natural immunization against a repeat episode.

How is tetanus diagnosed, and what is the prognosis of tetanus?

The diagnosis of tetanus is made clinically, based on a patient's history of exposure such as stepping on a rusty nail in the backyard, and by the symptoms present, such as "lockjaw," difficulty swallowing, fever, and generalized muscle spasms.

Once diagnosed and treated, the prognosis is generally good if the patient receives appropriate care early in the illness. The toxin does no permanent damage, and patients who receive appropriate supportive care generally recover. Sometimes symptoms develop rapidly, and some people live in remote areas where they are not able to receive appropriate care and are at a higher risk of death from tetanus.

Is it possible to prevent tetanus?

Active immunization ("tetanus vaccine") plays an essential role in preventing tetanus. Preventative measures to protect the skin from being penetrated by the tetanus bacteria are also important. For instance, precautions should be taken to avoid stepping on nails by wearing shoes. If a penetrating wound should occur, it should be thoroughly cleansed with soap and water and medical attention should be sought. Finally, passive immunization can be administered in selected cases (with specialized immunoglobulin).

What is the schedule for active immunization (tetanus shots)?

All children should be immunized against tetanus by receiving a series of five DTaP vaccinations, which generally are started at 2 months of age and completed at approximately 5 years of age. Booster vaccination is recommended at 11 years of age with Tdap.

Follow-up booster vaccination is recommended every 10 years thereafter. While a 10-year period of protection exists after the basic childhood series is completed, should a potentially contaminated wound occur, an "early" booster may be given in selected cases and the 10-year "clock" resets.

What are the side effects of tetanus immunization?

Side effects of tetanus immunization occur in approximately 25% of vaccine recipients. The most frequent side effects are usually quite mild (and familiar) and include soreness, swelling, and/or redness at the site of the injection. More significant reactions are extraordinarily rare. The incidence of this particular reaction increases with decreasing interval between boosters.

What is passive immunization (by way of specialized immunoglobulin)?

In individuals who exhibit the early symptoms of tetanus or in those whose immunization status is unknown or significantly out of date, the tetanus immunoglobulin (TIG) is given into the muscle surrounding the wound with the remainder of the dose given into the buttocks.